ICU谵妄患者病因分析以及处理

分析急诊ICU患者出现谵妄症状的原因以及处理对策。分析总结我院急诊ICU3年间所有患者的资料,发现20．2％的患者出现谵妄症状,原因为：（1）疾病相关;（2）药物相关;（3）监护环境等多种因素作用结果。经过调整治疗方案、加强心理护理后,需要镇静药物的仅为谵妄患者的19．7％。因此寻找谵妄原因很重要,治疗重点在于去除谵妄原因以及相关促发因素。     

Cortisol,interleukins and S100B in delirium in the elderly

In independent studies delirium was associated with higher levels of cortisol, interleukin(IL)s, and S100B. The aim of this study was to simultaneously compare cortisol, IL-6, IL-8, and S100B levels in patients aged 65 years and older admitted for hip fracture surgery with and without delirium. Cortisol, IL-6, IL-8, and S100B were assayed in repeated blood samples. 120 patients (mean age 84 years, 62 patients with delirium) were included. Highest levels of IL-8 (27.1, 95% Confidence Interval (CI): 13.6–53.1 pg/ml) and cortisol (666, 95% CI: 475–859 nmol/L) were before delirium, but of IL-6 (84.3, 95% CI: 46.5–151.4 pg/mL) and S100B (0.18, 95% CI: 0.12–0.24 μg/L) during delirium. In multivariable analysis cortisol, LogIL-6, and LogS100B were significantly associated with delirium, but adjusted for pre-existing cognitive impairment, only LogS100B remained significantly associated. Cortisol, IL-6 and S100B may have a role in the pathogenesis of delirium, but S100B is the strongest independent marker.     

Plasma ACTH, STH and other hormone levels in various groups under chlormethiazole, haloperidol or reserpine load in alchohol delirium, alcoholic hallucinations, and chronic alcoholism]

Studies of 135 men with safely diagnosed alcohol delirium mostly revealed increased ACTH blood values when sober and increased T4 values in about 1/3 of these patients. There is a correlation between the psychiatric clinical picture of the alcohol delirium and the ACTH content of the plasma. Under load with chloromethiazole, halperidole or with reserpine, there is a significant drop in the increased ACTH and T4 values. In an acute alcoholic hallucinosis (n=16) similar endocrinological changes as in most cases of safely diagnosed alcohol delirium were observed. In a chronic alcoholic hallucinosis (n=11) and in chronic alcoholics (n=31) the endocrinological values were similar to those of patients after alcohol delirium.     

Speech abnormalities in seizures: a comparison of absence and partial complex seizures

In order to determine whether speech changes are useful in differentiating seizure types, a study was done in which speech abnormalities during two distinct seizure types, partial complex and absence seizures, were compared. Speech changes noted during prolonged electroencephalographic and video monitoring were compared in 16 patients with 47 partial complex seizures and 19 patients with 95 absence seizures. Speech changes were common during both seizure types. Although some significant differences in speech patterns were noted in the two seizure types, the degree of overlap was such to preclude using speech changes alone as the sole clinical criteria in differentiating the seizures.     

Massively multiplayer online role-playing game-induced seizures: a neglected health problem in Internet addiction.

As the Internet has become rapidly and widely integrated into society, Internet addiction has become a growing psychosocial problem. However, epileptic seizure, another out-of-the-ordinary health problem, is often neglected in this regard. Ten patients who experienced epileptic seizures while playing the newest genre of electronic games -- Massively Multiplayer Online Role-Playing Games (MMORPGs) -- were investigated. Patients were predominantly male young adults, and most of the events were generalized tonic-clonic seizures, myoclonic seizures, and absences. These patients should be categorized into idiopathic generalized epilepsies. Even though photosensitivity was an important factor, behavioral and higher mental activities also seemed to be significant seizure precipitants. Results demonstrated that MMORPG-induced seizures were not analogous to the ordinary video game-induced seizures. Significantly, an epileptic seizure warning did not always appear on the websites of MMORPGs and instructions for the software. While the prevalence of MMORPG-induced seizures remains unknown, it may exceed our expectations and impact our society. Not only for clinical neurologists but also for the primary physicians, educators, sociologists, and global online game publishers, there should be an awareness of this special form of reflex seizures in order to provide an appropriate health warning to MMORPG players.     

ICU镇静药物的选择：苯二氮卓还是非苯二氮卓

2013年美国危重症医学会新发布的镇静、镇痛、谵妄治疗指南中指出,苯二氮卓类镇静药物的使用是ICU重症患者谵妄发生的独立危险因素,推荐ICU镇静优先采用非苯二氮卓类镇静药物以改善临床预后.的确,大量的研究表明以右美托咪定为代表的非苯二氮卓类药物相比苯二氮卓类镇静药,能明显缩短重症患者机械通气时间、ICU住院时间、减少ICU费用,并减少ICU谵妄的发生.然而事物总有两面性,ICU镇静不只是单凭药物调整便能顺理成章完成的事情.相比依据指南盲从简单的停用某种药物,建立完整的疼痛、躁动、谵妄评估系统,制定个体化镇静计划,保证机械通气有效性显得更为重要.     

Side-effects of lithium therapy]

Side-effects and complications of lithium therapy were examined by evaluation of data registered from 73 patients. Transitory subjective complaints would often occur during the initial phase of therapy, but they do not require any additional therapy. Occasional development of struma and sometimes high increase of body weight require regular controls of these values. Disposing factors concerning the possible occurrence of epileptic seizures and extra-pyramidal disorders under lithium therapy are Melipramin as well as organic cerebral lesions.     

The Association Between Delirium and Cognitive Decline: A Review of the Empirical Literature

Delirium is a common neurobehavioral syndrome that occurs across health care settings which is associated with adverse outcomes, including death. There are limited data on long-term cognitive outcomes following delirium. This report reviews the literature regarding relationships between delirium and cognitive impairment. Psych Info and Medline searches and investigation of secondary references for all English language articles on delirium and subsequent cognitive impairment were carried out. Nine papers met inclusion criteria and documented cognitive impairment in patients following delirium. Four papers reported greater cognitive impairment among patients with delirium than matched controls. Four papers reported higher incidence of dementia in patients with a history of delirium. One study found 1 of 3 survivors of critical illness with delirium developed cognitive impairment. The evidence suggests a relationship between delirium and cognitive impairment, although significant questions remain regarding the nature of this association. Additional research on delirium-related effects on long-term cognitive outcome is needed.     

Age-dependent consequences of seizures: relationship to seizure frequency, brain damage, and circuitry reorganization

Seizures in the developing brain pose a challenge to the clinician. In addition to the acute effects of the seizure, there are questions regarding the impact of severe or recurrent seizures on the developing brain. Whether provoked seizures cause brain damage, synaptic reorganization, or epilepsy is of paramount importance to patients and physicians. Such questions are especially relevant in the decision to treat or not treat febrile seizures, a common occurrence in childhood. These clinical questions have been addressed using clinical and animal research. The largest prospective studies do not find a causal connection between febrile seizures and later temporal lobe epilepsy. The immature brain seems relatively resistant to the seizure-induced neuronal loss and new synapse formation seen in the mature brain. Laboratory investigations using a developmental rat model corresponding to human febrile seizures find that even though structural changes do not result from hyperthermic seizures, synaptic function may be chronically altered. The increased understanding of the cellular and synaptic mechanisms of seizure-induced damage may benefit patients and clinicians in the form of improved therapies to attenuate damage and changes induced by seizures and to prevent the development of epilepsy.     

Cultural similarities in psychological reactions to infertility

A 74-item especially developed and validated questionnaire for Iranian culture was administered three times to 37 Iranian infertile couples and 10 fertile couples acting as control group, namely, initial consultation, during treatment, and on completion of treatment. In view of parallel data also reported for Western patients interest centered on the results of two out of the five factors measured by the questionnaire, i.e., Psychological Stress and Social Behaviour. Analysis generally showed significantly high stress and social withdrawal for the patient group, particularly at initial consultation and after an unsuccessful treatment cycle as compared to the control group. Moreover, men whose partners eventually conceived scored significantly lower on stress than men whose partners did not conceive. Similar results have also been reported for Western infertile patients. The implications of the findings are discussed.     

在美国样本中母亲抑郁症状与儿童退缩的关系:教养行为的中介作用

本研究通过使用美国国家儿童健康与人类发育研究所的纵向研究数据建立分层线性模型,探究在儿童的早期发展中,母亲抑郁症状对儿童的社会性退缩的影响,以及母亲的教养行为在这一关系中的中介作用,结果发现：（1）在儿童24~54个月期间,随着母亲抑郁症状的升高,儿童的社会性退缩也随之升高;（2）母亲抑郁症对儿童社会性退缩的影响存在着性别差异,与女孩相比,男孩的社会性退缩更容易受到母亲抑郁症状的影响;（3）在男孩中,消极的教养行为在母亲抑郁症状与男孩的社会性退缩之间起到了中介作用,而在女孩中,这一中介作用并不显著。     

Clinical significance of sleep status following-large scale epileptic attacks (grand mal)

Certain clinical criteria of grand mal seizures, and particularly the post-convulsive sleep phase (PCS), appear to be manifestations of some more deep-rooted disturbance of the functional cerebral mechanisms. The symptoms of the chronic organic psychosyndrome were observed distinctly more often in patients with PCS than in those without it. The frequency of seizures is also important when considering the cause of chronic brain damage. Etiological aspects (genuinely-symptomatological) appear to be of secondary importance.     

Clinical management of alcohol withdrawal

It has been well known for a number of years that abrupt withdrawal from alcohol following chronic use is associated with adverse consequences, ranging from mild tremors to withdrawal seizures. The overall purposes of treating alcohol withdrawal (AW) are to relieve patient discomfort, to prevent the development of more serious withdrawal symptoms, and to initiate long-term alcohol rehabilitation. Several areas of controversy exist in the clinical management of AW, including the optimal treatment setting, the need for pharmacologic management, and the most appropriate agent to prescribe when medication is deemed necessary. This article reviews the clinical features, general management, and treatment of AW.     

Psychosis associated with anti-N-methyl-D-aspartate receptor antibodies

We describe the eighth case study of a female diagnosed with anti-N-methyl-D-aspartate receptor encephalitis without an identified tumor who presented with floridly psychotic symptoms following a 2-week prodromal phase with new-onset headaches and presyncopal episodes. While hospitalized, the patient had seizures, autonomic dysfunction, involuntary movements, and a decline in mental status. A subsequent assay was positive for anti-N-methyl-D-aspartate receptor receptor antibodies. In contrast to most reported cases, an initial trial with corticosteroids was therapeutically unsuccessful. Subsequent treatment with intravenous immunoglobulins, however, resulted in a prompt, robust clinical response and enabled the patient to be rapidly discharged from the hospital, with minimal neuropsychiatric sequelae.     

Tobacco withdrawal and negative affect: an analysis of initial emotional response intensity and voluntary emotion regulation

This report used emotion-modulated startle to refine theoretically critical claims about negative affect during tobacco withdrawal. Forty-eight dependent smokers (assigned to either a 24-hr nicotine withdrawal condition or a continued smoking condition) and 48 nonsmokers participated in this study. Participants viewed a series of neutral and unpleasant photographic images and were instructed to enhance, suppress, or maintain their emotional response during specific trials. Participants' startle response was measured before and after this regulation instruction to index 2 components of emotional response: initial negative emotional response intensity and emotion regulation. Compared with the nonwithdrawn groups (continuing smokers and nonsmokers), withdrawal significantly increased self-reported negative affect. However, startle response indicated that emotional response intensity and emotion regulation success were not affected by withdrawal. These results are important because they constrain interpretation of the predominantly self-report literature on the affective consequences of tobacco withdrawal.     

Epileptic seizures in multiple sclerosis

Starting from informations in the literature, the authors deals with eight own cases, suffering from clinically certain multiple sclerosis and showing, as a further sign, epileptic seizures. Compared to the total of patients, these eight cases represent 1.78 p.c. of all patients treated for multiple sclerosis in this clinic. The features of seizures, frequency and dynamics of occurrence are referred to. The authors point out that it is necessary to differential between epileptic seizures and non-epileptic attacks, and they draw attention to the fact that here are difficulties with regard to differential diagnosis if epileptic seizure appears as a initial symptom of multiple sclerosis.     

EEG feedback training in the treatment of epilepsy: Some questions and some answers

A basic question in EEG feedback training of epileptic patients is whether the decrease in seizures is specifically due to the training or to other factors. Questions may also be raised as to what EEG changes are involved. Preliminary results in five patients suggest that seizure reductions can occur with training which are not due to placebo or nonspecific effects or to changes in medication compliance. These changes occurred rapidly during EEG-contingent feedback training but not when feedback was random in relation to the EEG. Reliable changes in the EEG were also observed, but the question of which mechanism accounts for these results has yet to be answered.     

Infants' social withdrawal and parents' mental health

This study examined the association of infants' sustained social withdrawal with parents' self-reported current depressive symptoms and perceived mental health. Two hundred and sixty infants aged 4, 8 and 18 months were examined with the Baby Alarm Distress Scale (ADBB). Parents' depressive symptoms and perceived mental health during the preceding year were elicited through questionnaires. Mother's current depressive symptoms and father's perceived moderate or poor mental health during the preceding year both independently increased the infant's risk of withdrawal. When both parents had mental health problems, the infant was more likely to be withdrawn. Infant's social withdrawal should alert clinicians to examine parental mental health. Also, if the parent has mental health problems, the infant's social behavior and possible withdrawal should be examined. Families where both parents experience poor mental health should be identified, and treated, while the infants of these families in particular seem to be at risk for social withdrawal.     

Morbidity rate in delirium tremens

On evaluating an analysis of 105 cases of delirium tremens over a period of five years in a psychiatric base-unit, the following findings were obtained: Delirium tremens, particularly in conjunction with secondary diseases, constitutes a life-endangering medical emergency and requires intensive medical treatment. Letality was 8,57%. The morbidity-rate and the relapse-rate showed a clearly marked increase; the age of contracting the disease had its frequency peak between 30 and forty, i. e. earlier than in many other statistical surveys. Epileptic attacks as symptoms starting off or accompanying delirium occurred in almost one third of our delirium patients. The impact which these attacks have on the development in the course of process-like alcoholism was discussed.     

Partial kindling and emotional bias in the cat: lasting aftereffects of partial kindling of the ventral hippocampus. I. Behavioral changes

Repeated electrical evocation of afterdischarges in the perforant-path ventral hippocampal system of the cat produces lasting changes in species characteristic behavioral responses to environmental threat. After 7 to 12 afterdischarges, cats showed greatly enhanced defensive (withdrawal) responses to rats, and mildly enhanced defensive responses toward mice. Measures of predatory attack which negatively correlate with withdrawal from rats were also changed in a direction consistent with the increase in withdrawal tendency. There was little effect of afterdischarges on the same parameters of attack on mice. Thus the stimulation seemed to attenuate predatory aggression by increasing defensive sensitivity to the threat posed by prey self-defense, and not by reducing predatory motivation per se. The change in defensiveness was not restricted to the predatory test situation, however. Tests of defensive response to conspecific threat vocalizations revealed an increased defensive responding to this stimulus as well. On the other hand, there was no change in social responsiveness shown toward a highly familiar human. Given the sudden onset (1 hr to 24 hr after the last afterdischarge), the long-lasting nature of the change (30-60 days) which persisted in the absence of seizures, and the generality of expression of the behavioral change, it was concluded that the afterdischarges produced an interictally maintained alteration in a defensive personality characteristic of the cats.